Change and reform.

Within the health care community, the first quarter of 1995 seems so much quieter than did the first quatter of 1994. The distant thunder of impending health care reform that preoccupied so many of us seems like a faint echo, a Kohutek of sorts. We all remember the comet Kohutek that, ,as supposed to light up the nighttime sky, and we all remember the fireworks that never were, but we would be mistaken to view the failure of the Clinton health care reform package as a political Kohutek. Nothing in my memory has so fundamentally caused a rethinking of health care as did the specter of government-driven health care reform. Similarly, nothing in my memory has so catalyzed change in health care delivery and reimbursement as did the fear of government-mandated change. I only wish I could view these as positive events. Fear has led not to the systematic change sought by eager reformers, but rather piecemeal and discordant changes, some of which may be good but some of which may be disastrous.

Hany and Louise, the creations of the insurance industry, bemoaned the lack of choice and freedom that might occur under a government-mandated system. I wonder how come Harry and Louise have been remarkably silent in the face of increased use of managed care, and other systems that more robustly deny consumers choices. The mythical couple suggested that we had to fear for our health when distant government bureaucrats could control our health care options. But who feels better knowing that industry is now setting the pace?

Managers consumed with cost containment and a survivalist mentality are now playing the role we feared to give to the government. To whom are they ultimately responsible? When elected officials failed to seize the initiative, others moved into the vacuum, some with good intent, some out of necessity, and some out of opportunistic zeal. This may not be reform, but it is change and we had better lose our illusions about the past 2 years--reform may not be the word for what we have seen, revolution may be the more appropriate descriptor.

Physical therapists have played too small a role in the revolution that we have seen. We already are spending too much time bemoaning the changes in reimbursement and institutional structures that surround us. The time has come for us to consider the levels at which we must interact with a health care enterprise that lives in a state of chaos and flux. Our patients cannot go away until we sort out the mess that is our current reimbursement and access schemes. Therefore, it remains socially irresponsible for us not to find the most effective means for dealing with patient problems within the confines of existing reimbursement and organizational structures. We also would be irresponsible if we did not document and prove in a scientific manner how we and our patients are compromised by any system that we feel is inappropriate.

On a second level, we must remain active and participatory in the dialogue relating to change. This means activism within the organizations that employ our services, and activism at all governmental levels. We should look toward changing systems and mechanisms that we find at odds with good practice and patient interests, but that does not mean we can be excused from maximizing our function before change can take place. Clinicians who suggest that they are above or beyond the confines of the changes occurring in health care are elitists living in a dream world of self-indulgence. The world is as it is, and that is where we find our patients; therefore, it is time we engage our profession at all levels in efforts to improve care.

While I may personally decry the failure of our society to obtain universal access and a coherent means for managing our health care services and expenses, I cannot afford to avoid the reality that surrounds me. We must still find the means to care for the underinsured and the uninsured, and for providing the best reasonable care to all segments of our society. In the rush to silence the last echoes of the health care reform debate, let us never forget that changes have taken place and that we have yet to see whether the future we feared was worse than the future we have created.